a Control number

22222

Void

For Official Use Only OMB No. 1545-0008 1 Wages, tips, other compensation 2 Samoa income tax withheld

b Employer identification number

$
c Employer’s name, address, and ZIP code 3 Social security wages

$
4 Social security tax withheld

$
5 Medicare wages and tips

$
6 Medicare tax withheld

$
7 Social security tips

$
8

$
d Employee’s social security number 9 10

e Employee’s first name and initial

Last name

11

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

$
13

C o d e C o d e

12a See Form W-3SS instructions

$ $ $ $

12b

14

Other

12c
C o d e

12d
C o d e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa Wage and Tax Statement

2001
Cat. No. 10140H

Department of the Treasury—Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice and instructions, see Form W-3SS.

Copy A For Social Security Administration—Send this entire page with Copy A of Form W-3SS to the Social Security Administration; photocopies are not acceptable.

Do Not Cut, Fold, or Staple Forms on This Page — Do Not Cut, Fold, or Staple Forms on This Page

a Control number

22222

Void

OMB No. 1545-0008 1 Wages, tips, other compensation 2 Samoa income tax withheld

b Employer identification number

c Employer’s name, address, and ZIP code

3

Social security wages

4

Social security tax withheld

5

Medicare wages and tips

6

Medicare tax withheld

7

Social security tips

8

d Employee’s social security number

9

10

e Employee’s first name and initial

Last name

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a
C o d e

12b
C o d e

14

Other

12c
C o d e

12d
C o d e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa Wage and Tax Statement

2001

Department of the Treasury—Internal Revenue Service

Copy 1—For American Samoa Treasurer

a Control number

22222

Void

OMB No. 1545-0008 1 Wages, tips, other compensation 2 Samoa income tax withheld

b Employer identification number

c Employer’s name, address, and ZIP code

3

Social security wages

4

Social security tax withheld

5

Medicare wages and tips

6

Medicare tax withheld

7

Social security tips

8

d Employee’s social security number

9

10

e Employee’s first name and initial

Last name

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

12a
C o d e

12b
C o d e

14

Other

12c
C o d e

12d
C o d e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa Wage and Tax Statement

2001

Department of the Treasury—Internal Revenue Service

Copy 1—For American Samoa Treasurer

a Control number OMB No. 1545-0008 b Employer identification number 1 3 Wages, tips, other compensation Social security wages 2 4 Samoa income tax withheld Social security tax withheld

c Employer’s name, address, and ZIP code

5

Medicare wages and tips

6

Medicare tax withheld

7

Social security tips

8

d Employee’s social security number

9

10

e Employee’s first name and initial

Last name

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

C o d e C o d e

12a See instructions on back of Copy C

12b

14

Other

12c
C o d e

12d
C o d e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa Wage and Tax Statement

2001

Department of the Treasury—Internal Revenue Service This information is being furnished to the Tax Department, American Samoa Government.

Copy B—To Be Filed With Employee’s American Samoa Tax Return

a Control number OMB No. 1545-0008 b Employer identification number 1 Wages, tips, other compensation 2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3

Social security wages

4

Social security tax withheld

5

Medicare wages and tips

6

Medicare tax withheld

7

Social security tips

8

d Employee’s social security number

9

10

e Employee’s first name and initial

Last name

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

C o d e C o d e

12a See instructions on back

12b

14

Other

12c
C o d e

12d
C o d e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa Wage and Tax Statement

2001

Department of the Treasury—Internal Revenue Service This information is being furnished to the Tax Department, American Samoa Government.

Copy C—For EMPLOYEE’S RECORDS

Notice to Employee
File Copy B of this form with your 2001 American Samoa income tax return. Keep Copy C for your records. If your name, social security number (SSN), or address is incorrect, correct Copies B and C, and ask the employer to correct your employment record. Be sure to ask your employer to file Form W-2c, Corrected Wage and Tax Statement, with the Social Security Administration (SSA) to correct any name, amount, or SSN error reported to the SSA. If you expect to owe self-employment tax of $1,000 or more for 2002, you may have to make estimated tax payments to the U.S. Internal Revenue Service. Use Form 1040-ES, Estimated Tax for Individuals. Box 11. This amount is (a) reported in box 1 if it is a distribution from a nonqualified deferred compensation or section 457 plan or (b) included in box 3 and/or 5 if it is a prior year deferral under a nonqualified or section 457 plan that became taxable for social security and Medicare taxes this year because there is no longer a substantial risk of forfeiture of your right to the deferred amount. Box 12. The following list explains any codes shown in box 12. You may need this information to complete your tax return. A—Uncollected social security tax on tips B—Uncollected Medicare tax on tips C—Cost of group-term life insurance over $50,000 (included in boxes 1, 3 (up to social security wage base), and 5) D—Elective deferrals to a section 401(k) cash or deferred arrangement. Also includes deferrals under a SIMPLE retirement account that is part of a section 401(k) arrangement. E—Elective deferrals under a section 403(b) salary reduction agreement F—Elective deferrals under a section 408(k)(6) salary reduction SEP G—Elective deferrals and employer contributions (including nonelective deferrals) to a section 457(b) deferred compensation plan H—Elective deferrals to a section 501(c)(18)(D) tax-exempt organization plan (You may be able to deduct.)

J—Nontaxable sick pay (not included in boxes 1, 3, or 5) M—Uncollected social security tax on cost of group-term life insurance over $50,000 (former employees only) N—Uncollected Medicare tax on cost of group-term life insurance over $50,000 (former employees only) P—Excludable moving expense reimbursements paid directly to employee (not included in boxes 1, 3, or 5) Q—Military employee basic housing, subsistence, and combat zone compensation R—Employer contributions to your medical savings account (MSA) S—Employee salary reduction contributions under a section 408(p) SIMPLE (not included in box 1) T—Adoption benefits (not included in box 1) V—Income from exercise of nonstatutory stock option(s) (included in boxes 1, 3 (up to social security wage base), and 5) Box 13. If the “Retirement plan” checkbox is marked, special limits may apply to the amount of traditional IRA contributions you may deduct. Also, the elective deferrals in box 12 (codes D, E, F, G, H, and S) (for all employers, and for all such plans to which you belong) are generally limited to $10,500. Elective deferrals for section 403(b) contracts are limited to $10,500 ($13,500 in some cases; see Pub. 571). Section 457(b) plans are limited to $8,500. Amounts over these limits must be included in income. Credit for excess social security tax. If you had more than one employer in 2001 and more than $4,984.80 in social security tax was withheld, you may have the excess refunded by filing Form 843, Claim for Refund and Request for Abatement, with the Internal Revenue Service Center in Philadelphia. If you must file Form 1040 with the United States, claim the excess tax as a credit on Form 1040. Note: Keep Copy C of Form W-2AS for at least 3 years after the due date for filing your income tax return. However, to help protect your social security benefits, keep Copy C until you begin receiving social security benefits, just in case there is a question about your work record and/or earnings in a particular year. Review the information shown on your annual (for workers over 25) Social Security Statement.

a Control number Void b Employer identification number OMB No. 1545-0008 1 Wages, tips, other compensation 2 Samoa income tax withheld

c Employer’s name, address, and ZIP code

3

Social security wages

4

Social security tax withheld

5

Medicare wages and tips

6

Medicare tax withheld

7

Social security tips

8

d Employee’s social security number

9

10

e Employee’s first name and initial

Last name

11 13

Nonqualified plans
Statutory employee Retirement plan Third-party sick pay

C o d e C o d e

12a See Form W-3SS instructions

12b

14

Other

12c
C o d e

12d
C o d e

f Employee’s address and ZIP code

Form

W-2AS

American Samoa Wage and Tax Statement

2001

Department of the Treasury—Internal Revenue Service For Privacy Act and Paperwork Reduction Act Notice and instructions, see Form W-3SS.

Copy D—For Employer

Instructions for Preparing Form W-2AS
Note: A minimum income tax of 2% must be withheld on wages and other compensation. Who must file. File Form W-2AS for each employee from whom American Samoa income tax or U.S. social security and Medicare taxes were withheld or required to be withheld during 2001. Distribution of copies. By January 31, 2002, furnish Copies B and C to each person who was your employee during 2001. For anyone who stopped working for you before the end of 2001, you may furnish Copies B and C to them any time after employment ends but by January 31. If the employee asks for Form W-2AS, furnish the completed copies within 30 days of the request or within 30 days of the final wage payment, whichever is later. You may also file Copy A and

Form W-3SS, Transmittal of Wage and Tax Statements, with the Social Security Administration at the same time. Note: If you terminate your business, see the rules on furnishing and filing Forms W-2AS and W-3SS under Terminating a business in the Form W-3SS instructions. When to file. By February 28, 2002, send Copy A of Forms W-2AS and W-3SS to the Social Security Administration. However, if you file electronically (not by magnetic media), the due date is April 1, 2002. See Form W-3SS. Reporting on magnetic media or electronically. If you must file 250 or more Forms W-2AS, you must file using magnetic media or electronically. For information, contact your Employer Service Liaison Officer (ESLO) at 510-970-8247. See Form W-3SS for more information on how to complete Form W-2AS.